The report is a product of the VA/HSR Evidence Synthesis Program.

Moral Injury and Mental Health Among U.S. Military Service Members and Veterans: A Systematic Review and Evidence Overview

Takeaway: Moral injury (MI) symptoms among Veterans and military service members are likely correlated with greater PTSD, depression, and anxiety symptom severity, and exposure to potentially morally injurious events (PMIEs) may be correlated with greater symptom severity. MI symptoms and PMIE exposure may be correlated with increased suicidal thoughts and behaviors, greater substance use, and poorer relationship functioning and social engagement.

Military service members may be exposed to situations in which their own actions or the actions of others conflict with deeply held values. Moral injury (MI) describes an intense and distressing response to such exposures, which are referred to as potentially morally injurious events (PMIEs). MI is characterized by feelings of guilt and shame, loss of trust, and loss of meaning or purpose. MI-related constructs have been linked to adverse psychosocial outcomes among Veterans and military service members. While MI is still an evolving construct, the pace of new research on MI has been accelerating, and the concept of MI is increasingly being applied to non-military populations, such as healthcare workers.

In response to a request from the Integrative Mental Health (IMH) initiative, supported by the VHA Office of Mental Health and Suicide Prevention, HSR’s Evidence Synthesis Program (ESP) Center in Portland, OR, characterized the published literature on MI broadly across populations and synthesized available evidence on the relationship between PMIEs and MI and mental health outcomes among Veterans and military service members.

ESP investigators identified 282 relevant primary studies and 29 relevant reviews in MEDLINE and PsycINFO through February 2024.

Summary of Findings

• Most studies examined associations between PMIEs or MI and other variables, such as mental health symptoms, or described the development or validation of a PMIE/MI measure. Fewer studies reported on development or evaluation of MI-specific interventions, and few studies evaluated the efficacy of MI-specific interventions in randomized controlled trials.
• Among Veterans and military service members, MI symptoms are likely correlated with greater PTSD, depression, and anxiety symptom severity, and PMIE exposure may also be correlated with greater symptom severity.
• Among Veterans and military service members, MI symptoms and PMIE exposures may be correlated with increased suicidal thoughts and behaviors, greater substance use, and poorer relationship functioning and social engagement.
• Future research on the associations between PMIE exposures, MI, and adverse mental health outcomes using recently developed, improved measures to assess PMIE exposure and MI symptoms will further clarify these associations.

Implications

Findings from this review will inform IMH’s efforts to address the STRONG Veterans Act, which directs VA to conduct research on how MI relates to the mental health needs of Veterans who served in the Armed Forces after September 11, 2001, and to identify best practices for mental health treatment among these Veterans. This review’s findings will also help guide future VA research on PMIE and MI.

Limitations

Nearly all identified studies provide cross-sectional data, which can characterize associations between PMIEs/MI and other variables but cannot be used to determine the causal nature of these relationships. Further, PMIE and MI measures used by the included studies have faced criticism for inadequate examination of validity and for failing to index MI outcomes to PMIE exposures. Limitations of the ESP team’s review methods include use of sequential rather than dual independent review for some steps. In addition, it is possible that some of the included studies have overlapping samples.

Future Research

Future longitudinal research is needed to clarify the causal pathway between PMIE exposures, the development of MI, and adverse mental health outcomes. As PMIE and MI constructs are better understood in relation to established diagnoses such as PTSD, future research should also develop and evaluate treatment interventions.

Citation:

Beech EH, Mackey KM, Parr NJ, Baltich Nelson B, Young S, Belsher BE. Moral Injury and Mental Health among US Military Service Members and Veterans: A Systematic Review and Evidence Overview. Washington, DC: Evidence Synthesis Program, Health Systems Research, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-199; 2024.

To view the full report, go to https://www.hsrd.research.va.gov/publications/esp/moral-injury.cfm.

How can VA leadership work with the ESP? Nominations for systematic review topics may be submitted to the program at any time. When you submit a topic nomination form, ESP Coordinating Center staff will work with you to determine the appropriate research approach and ESP product to address your questions of interest. Topics are selected and assigned to an ESP Center based on program capacity and alignment with VA national goals.

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers; and to disseminate these reports throughout VA.

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